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A 60-year-old pianist with pain and swelling of the left long finger

Issue: April 2014

ByJenniefer Y. Kho, MD

ByApurva S. Shah, MD, MBA

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A 60-year-old right-hand dominant pianist presented to clinic with complaints of pain and swelling of her left long finger metacarpophalangeal joint. She reported mild symptoms during the past 15 years, but the pain had significantly worsened during the last year and a half. She also reported mild discomfort in her left index metacarpophalangeal and right small metacarpophalangeal joints. There was no history of trauma or other inciting event.

She stated her pain was worse at night, with minimal morning stiffness. Activities of daily living and recreational activities, such as gardening, exacerbated her pain. Due to discomfort, she was unable to play the piano. She noted color changes of her index and long fingers with cold weather. She was initially treated with NSAIDs and a corticosteroid injection of the long metacarpophalangeal (MCP) joint, which alleviated her pain for several weeks. A repeat injection provided no relief and she had poor tolerance to chronic NSAID use.

Figure 1. Physical examination of the left
hand was notable for shortening of the
long finger (solid arrow) and prominent
swelling of the long meta-carpophalengeal
joint (dotted arrow).

Images: Kho JY and Shah AS

Her past medical history was unremarkable, and her family history was negative for inflammatory or rheumatologic disease. There was no history of oral or parenteral steroid use. She smoked roughly a pack of cigarettes a week and occasionally consumed wine with dinner.

Physical examination and imaging

Physical exam was notable for prominent swelling, erythema and tenderness to palpation of the left long MCP joint. Inspection revealed shortening of the long finger ray (Figure 1). The interphalangeal joints were not affected, and she had full range of motion of the wrist and other digits. A neurovascular exam of the patient was unremarkable. Erythrocyte sedimentation rate (ESR), C-reactive protein and immunological test results were within normal limits.

Anteroposterior (AP), oblique and lateral radiographs of the hand showed destructive changes of the long metacarpal head with flattening, irregularity and shortening (Figures 2a and 2b). The surrounding MCP joints were not involved.

Figure 2. AP radiograph of both hands (a) and oblique radiograph of the left hand demonstrated flattening and shortening of the long metacarpal head with cystic and sclerotic changes (b). Surrounding joints were not involved. Incidental findings included two foreign bodies in the index and long fingertips.

MRI without contrast demonstrated a low T1, high T2 signal in the long metacarpal head with capsular distension. There was also irregularity of the long metacarpal head with mild surrounding enhancement and signs of edema extending into the diaphysis. No imaging abnormalities were detected in the left index and right small MCP joints.

What is your diagnosis?

See answer on next page.

Avascular necrosis of metacarpal head (Dieterich’s Disease)

Idiopathic avascular necrosis (AVN) of the metacarpal head is a rare condition, first described by Dieterich in 1932. It commonly affects the long metacarpal head, followed by the index, ring and small fingers, and rarely affects the thumb. Etiologic factors frequently cited include trauma, steroid use and systemic lupus erythematous. Patients aged 6 years to 54 years have been diagnosed. Idiopathic AVN has been described to have similar clinical and radiographic findings as Freiberg’s infarction of the metatarsal. Treatment options are variable, although similar surgical principles have been applied to the management of AVN of the hand with that of the femoral head, knee and foot.

The mechanism by which steroid use causes AVN is thought to be secondary to intravascular occlusion by fat emboli. Variation in vascular supply may also be a predisposing factor to AVN. Wright and Dell performed dissections of 50 metacarpal specimens, and reported absence of the main arteriole to the distal epiphysis in 35% of the specimens, making them dependent on small pericapsular arterioles. They postulated that absence of the main artery, in combination with trauma, systemic lupus erythematous, steroid use or other risk factors, might make these metacarpals more susceptible to AVN. Repetitive microtrauma resulting in joint effusion compresses the small arterioles and leads to ischemia.

Work-up

Symptoms include a gradual onset of pain, swelling and stiffness of the MCP joint with usually with no obvious trauma. History should elicit questions regarding steroid use, vasculitides such as lupus, hypercoagulability disorder, renal transplant and inflammatory diseases. Physical exam reveals swelling of the MCP joint with focal tenderness over the metacarpal head and restricted range of motion. Laboratory work-up includes ESR, plasma viscosity, coagulation screening, lupus screening, rheumatologic testing and serum electrophoresis.

Although a radiographic staging system has not been described, similar findings as would be seen in femoral head osteonecrosis can be observed. Plain radiographs will demonstrate subchondral lucency, flattening or irregularity of the metacarpal head, cystic or sclerotic changes, and joint space narrowing. MRI can be helpful in confirming the diagnosis of AVN, especially if early radiographic findings are subtle. There will be low T1 signal and corresponding high T2 signal of the metacarpal head indicating ischemia, joint effusion and potentially a subchondral fracture. The MRI can demonstrate the integrity of the articular cartilage and extent of disease. Radionuclide bone scan will show increased uptake at the MCP joint, and involvement of other sites in patients at risk for AVN.

Figure 3. Intraoperative AP (a) and lateral fluoroscopic image (b) of final silicone MCP implant position.

Treatment options

Nonoperative management consists of immobilization, NSAIDs and activity modification. The natural history is variable, with some patients being asymptomatic and others developing worsening pain, range of motion and collapse. Although progressive degenerative arthritis may occur, spontaneous clinical and radiographic resolution has been reported in pediatric cases. A 14-year-old who underwent nonsurgical treatment and was followed for 33 months after his symptoms began had full and pain-free range of motion, although with incongruity of the MCP joint. Surgical options for persistent symptoms include decompression or curettage and bone grafting vs. arthrodesis or arthroplasty. The integrity of the articular cartilage may direct the surgeon towards a joint-preserving vs. a joint-sacrificing procedure. Other surgical techniques, such as volar flexion osteotomy and osteochondral mosaicplasty, are alternative options.

Decompression or curettage and bone grafting is carried out through a dorsal approach to the extensor expansion and capsule. The articular surface is inspected for any erosion, articular flaps or defects. Multiple drill holes are made with a Kirschner wire just proximal to the articular cartilage at the bone-cartilage junction. If curettage is to be performed, a 2-mm drill can be used to create an entry hole, and curettes and/or burrs are used to remove sclerotic or necrotic bone. The cavity is packed with cancellous bone graft harvested from the distal radius. The hand is immobilized for 2 weeks to 3 weeks, followed by active mobilization as tolerated.

Figure 4. AP radiograph 8 months after
surgery demonstrated stable component
position in the left long finger MCP joint
with good alignment and no evidence of
loosening or fracture.

Wada and colleagues described a volar flexion osteotomy of the third metacarpal neck in a 16-year-old with idiopathic AVN. The surgeons likened this procedure to a dorsiflexion osteotomy of the metatarsal head for treatment of Freiberg’s disease. Arthroscopy of the MCP joint was performed first to confirm intact dorsal metacarpal head cartilage. The osteotomy site was wedged open with corticocancellous distal radius bone graft, such that healthy dorsal cartilage of the metacarpal head articulated with the proximal phalanx. This was stabilized with 0.064-mm Kirschner wires. At 4-year follow-up, the patient had a painless range of motion (10° to 80°) with a healed osteotomy, but had persistent incongruity of the metacarpal head.

Maes and colleagues published a case report on autologous osteochondral mosaicplasty in a 31-year-old man with bilateral AVN of the long finger metacarpal head. An 8-mm osteochondral plug from the lateral femoral condyle was harvested and impacted into bilateral defects located on the dorsal metacarpal head. At 1-year follow-up, there was painless range of motion on one side with residual symptoms of the left hand. CT scan confirmed incorporation of both grafts, although there were mild degenerative changes on the left hand. The authors recommended this technique for cases in which the dorsal articular surface of the metacarpal head is collapsed.

In regards to arthrodesis versus arthroplasty of the MCP joint of the fingers, arthroplasty is favored in order to preserve motion and function. Hinged silicone implants or nonconstrained metal-plastic or pyrolytic carbon implants are commonly used in degenerative and inflammatory diseases. Silicone elastomer joint spacers provide inherent stability, but are subject to rotation and lateral deformation. These implants depend on the integrity and quality of the surrounding tissue for stability, and are better tolerated in non-border digits. Silicone implants are prone to fracture over time and can cause synovitis or osteolysis, but with far less frequency and severity than treatment with carpal implants. Pyrolytic carbon offers the advantage of exceptional wear characteristics and can be used as a hemiarthroplasty, as its modulus of elasticity is similar to that of cortical bone. If arthrodesis is chosen, the joint must be well-prepared, and fixation can be performed with screws, plates or wires.

Management of our patient

Our patient was diagnosed with idiopathic AVN of the metacarpal head, with a possible inciting factor being repetitive microtrauma due to her occupation as a pianist. Due to the advanced stage of AVN with articular collapse and deformity, we presented two surgical options: MCP arthrodesis or arthroplasty. The patient preferred a motion-sparing procedure, which was important for her as a pianist. Therefore, she was indicated for silicone arthroplasty.

Under tourniquet exsanguination, a longitudinal incision was made over the extensor mechanism, and the radial sagittal band was released. The MCP joint was exposed, and a cutting guide was utilized to resect the joint. The collaterals were protected with retractors. The metacarpal and phalanx were broached to a size 30, and a size 30 Ascension silicone MCP implant (Ascension Orthopedics Inc.; Austin, Texas) was placed and its position confirmed fluoroscopically (Figure a and b). The radial sagittal band was imbricated and skin closed in standard fashion. The joint was immobilized in a splint for 1 month, then discontinued to allow for range of motion was tolerated.

At 3-month follow-up, the patient reported that she had returned to playing the piano without complications. There was resolution of pain and swelling, and MCP motion was 3° of hyperextension to 89° of flexion. She was able to make a full composite fist with good grip strength. Radiographs taken at 8 months demonstrated stable component position (Figure 4). At 1-year follow-up, she was doing well in terms of the arthroplasty, although she developed triggering of the ring and small fingers and swan-neck deformity of the ring finger. These have been managed conservatively with steroid injection and splinting.